Provider Demographics
NPI:1386283091
Name:TOM, JONATHAN N (DO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:N
Last Name:TOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 N ALTURA RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-6059
Mailing Address - Country:US
Mailing Address - Phone:626-272-8983
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-4853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20879207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program